Sensation seeking, binge-type eating disorders, victimization, and PTSD in the National Women's Study

The intersection of trauma and eating disorders: evaluating cognitive processing therapy through qualitative analysis

Quantitative research has demonstrated that many individuals with eating disorders (EDs) present with PTSD (ED-PTSD). Cognitive processing therapy (CPT) has been integrated into the overall treatment for ED-PTSD, but qualitative data on the effectiveness of this approach is lacking. Ten patients with ED-PTSD completed 12 sessions of CPT during residential treatment (RT). After sessions 1 and 11, patients wrote an "impact statement" clarifying their beliefs about why their trauma occurred and how it has impacted their life. Two coders using MAXQDA2020 software evaluated these statements using a structured coding protocol to assess changes in trauma-related cognitions over time. Analyses of these cognitive changes demonstrated shifts in the appraisal process regarding why trauma occurred from stances of self-blame to external fault. Exploratory analyses also indicated that perceptions of control and safety were associated with a greater frequency of reference to EDs and body image. Qualitative findings demonstrated that trauma-related cognitions became more realistic and adaptive following CPT as evidenced by a significant reduction in assimilated and overaccommodated cognitions, and an increase in accommodated cognitions. Last, there was a notable shift in perceived responsibility for trauma and improvements in control and safety in relation to EDs.

The correlates of appearance focused self-concept: personality traits, self-concept, sociocultural, and early life experience factors

BACKGROUND

Theory and research indicate that an appearance focused self-concept (i.e., placing overriding importance on physical appearance for self-definition and self-worth) plays a role in the etiology and maintenance of disordered eating and eating disorders. Although the consequences of an appearance focused self-concept are palpable, less is known about its correlates. Accordingly, we examined a range of factors that may characterize appearance focused people, including personality traits (perfectionism, impulsivity, sensation-seeking, hopelessness, and anxiety sensitivity), self-concept (global self-esteem and self-concept clarity), sociocultural (thin-ideal, muscular-ideal, general attractiveness internalizations, and perceived pressure to be thin), and early life experiences (adverse childhood experiences, attachment styles) factors.

METHODS

Female undergraduate university students (N = 568; Mage = 19.58, SDage = 4.24) completed a questionnaire battery that included the Beliefs About Appearance Scale, Depressive Experiences Questionnaire-Self-Criticism-6 Scale, Frost-Multidimensional Perfectionism Scale, the Revised Almost Perfect Scale, Substance Use Risk Profile Scale, Self-Concept Clarity Scale, Rosenberg Self-Esteem Scale, Sociocultural Attitudes Towards Appearance Questionnaire-4 Scale, Adverse Childhood Experiences Questionnaire, Experiences in Close Relationships Scale Short Form, and the Dietary Restraint subscale of the Eating Disorders Examination Questionnaire.

RESULTS

Multiple regression analyses were conducted for each set of factors separately and together. For personality traits, perfectionism, impulsivity, and anxiety sensitivity were uniquely associated with appearance focused self-concept. For self-concept, global self-esteem and self-concept clarity were uniquely associated with appearance focused self-concept. For sociocultural, general attractiveness internalization, thin-ideal internalization, and perceived pressure to be thin were uniquely associated with appearance focused self-concept. For early life experiences, attachment anxiety and avoidance were uniquely associated with appearance focused self-concept. In the combined analysis, the various factors explained 54% of the variance in appearance focused self-concept. Impulsivity, global self-esteem, general attractiveness internalization, and perceived pressure to be thin were uniquely associated with appearance focused self-concept.

CONCLUSIONS

Results for global self-esteem were consistent with prior research. Findings for evaluative concerns perfectionism were inconsistent with prior research. We discuss future research directions to examine the link between evaluative concerns perfectionism and appearance focused self-concept. We also discuss how sociocultural factors (general attractiveness internalization and perceived pressure to be thin) and impulsivity may help cultivate an appearance focused self-concept, advancing knowledge on the characteristics of appearance-focused people.

Neurodevelopmental Model Explaining Associations between Sex Hormones, Personality, and Eating Pathology

Clinical scientists have been investigating the relationships between sex hormones, personality, and eating disorders for decades. However, there is a lack of direct research that addresses whether personality mediates or moderates the relationships between sex hormones and eating pathology. Moreover, the neural mechanisms that underlie the interactive associations between these variables remain unclear. This review aims to summarize the associations between these constructs, describe a neural mechanism mediating these relationships, and offer clinical strategies for the early identification and intervention of eating disorders. The gathered evidence shows that aggressiveness, impulsivity, and obsessive-compulsiveness may mediate or moderate the relationships between sex hormones and eating pathology, but only among females. Furthermore, sex hormone receptor density in the mesocorticolimbic dopamine pathway may explain the neural mechanism of these associations. Future research should use more comprehensive personality measurements and assess the mediation and moderation effects of temperament while taking the hormone levels of women across menstrual cycles into account. Additionally, electroencephalography and functional magnetic resonance imaging should be implemented to directly assess brain activity and corroborate these findings.

The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines

Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.

Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results

INTRODUCTION

We studied whether provisional posttraumatic stress disorder (PTSD) moderated discharge (DC) and 6-month follow-up (FU) outcomes of multi-modal, integrated eating disorder (ED) residential treatment (RT) based upon principles of cognitive processing therapy (CPT).

METHODS

ED patients [N = 609; 96% female; mean age (± SD) = 26.0 ± 8.8 years; 22% LGBTQ +] with and without PTSD completed validated assessments at admission (ADM), DC and 6-month FU to measure severity of ED, PTSD, major depressive disorder (MDD), state-trait anxiety (STA) symptoms, and eating disorder quality of life (EDQOL). We tested whether PTSD moderated the course of symptom change using mixed models analyses and if ED diagnosis, ADM BMI, age of ED onset and LGBTQ + orientation were significant covariates of change. Number of days between ADM and FU was used as a weighting measure.

RESULTS

Despite sustained improvements with RT in the total group, the PTSD group had significantly higher scores on all measures at all time points (p ≤ .001). Patients with (n = 261) and without PTSD (n = 348) showed similar symptom improvements from ADM to DC and outcomes remained statistically improved at 6-month FU compared to ADM. The only significant worsening observed between DC and FU was with MDD symptoms, yet all measures remained significantly lower than ADM at FU (p ≤ .001). There were no significant PTSD by time interactions for any of the measures. Age of ED onset was a significant covariate in the EDI-2, PHQ-9, STAI-T, and EDQOL models such that an earlier age of ED onset was associated with a worse outcome. ADM BMI was also a significant covariate in the EDE-Q, EDI-2, and EDQOL models, such that higher ADM BMI was associated with a worse ED and quality of life outcome.

CONCLUSIONS

Integrated treatment approaches that address PTSD comorbidity can be successfully delivered in RT and are associated with sustained improvements at FU. Improving strategies to prevent post-DC recurrence of MDD symptoms is an important and challenging area of future work.

Adverse childhood experiences and binge-eating disorder in early adolescents

BACKGROUND

Adverse childhood experiences (ACEs) are common and linked to negative health outcomes. Previous studies have found associations between ACEs and binge-eating disorder (BED), though they have mainly focused on adults and use cross-sectional data. The objective of this study was to examine the associations between ACEs and BED in a large, national cohort of 9-14-year-old early adolescents in the US.

METHODS

We analyzed prospective cohort data from the Adolescent Brain Cognitive Development (ABCD) Study (N = 10,145, 2016-2020). Logistic regression analyses were used to determine the associations between self-reported ACEs and BED based on the Kiddie Schedule for Affective Disorders and Schizophrenia at two-year follow-up, adjusting for sex, race/ethnicity, baseline household income, parental education, site, and baseline binge-eating disorder.

RESULTS

In the sample, (49% female, 46% racial/ethnic minority), 82.8% of adolescents reported at least one ACE and 1.2% had a diagnosis of BED at two-year follow-up. The mean number of ACEs was higher in those with a diagnosis of BED compared to those without (2.6 ± 0.14 vs 1.7 ± 0.02). The association between number of ACEs and BED in general had a dose-response relationship. One ACE (adjusted odds ratio [aOR] 3.48, 95% confidence interval [CI] 1.11-10.89), two ACEs (aOR 3.88, 95% CI 1.28-11.74), and three or more ACEs (aOR 8.94, 95% CI 3.01-26.54) were all associated with higher odds of BED at two-year follow-up. When stratified by types of ACEs, history of household mental illness (aOR 2.18, 95% 1.31-3.63), household violence (aOR 2.43, 95% CI 1.42-4.15), and criminal household member (aOR 2.14, 95% CI 1.23-3.73) were most associated with BED at two-year follow-up.

CONCLUSIONS

Children and adolescents who have experienced ACEs, particularly household challenges, have higher odds of developing BED. Clinicians may consider screening for ACEs and providing trauma-focused care when evaluating patients for BED.

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Relationship between sensation seeking, alcohol problems and bulimic symptoms: a community-based, longitudinal study

PURPOSE

The association of bulimic symptoms with sensation seeking is uncertain; however, both behaviors have been linked to alcohol problems. We assessed in a longitudinal, community-based setting whether sensation seeking in adolescence is associated with bulimic symptoms in early adulthood, also accounting for alcohol problems.

METHODS

Finnish men (N = 2000) and women (N = 2467) born between 1974-1979 completed Zuckerman's sensation seeking scale (SSS) at age 18. Alcohol problems (Malmö-modified Michigan alcoholism screening test (Mm-MAST) and bulimic symptoms [eating disorder inventory-2, bulimia subscale (EDI-Bulimia), population and clinical scoring systems] were defined at age 22-27. We examined relationships between SSS, Mm-MAST, and EDI-Bulimia using Pearson's correlation coefficient (r) and linear regression.

RESULTS

Alcohol problems were moderately correlated with sensation seeking and bulimic symptoms (population scoring) among women and men (r = 0.21-0.31). The correlation between sensation seeking and bulimic symptoms (population scoring) was weak among men (r = 0.06, p = 0.006) and even weaker and non-significant among women (r = 0.03, p = 0.214). Adjustment for alcohol problems removed the association between sensation seeking and bulimic symptoms among men. Furthermore, there were no significant correlations between sensation seeking and bulimic symptoms when assessing EDI-Bulimia clinical scoring.

CONCLUSION

Sensation seeking and bulimic symptoms were not associated among women. The association between sensation seeking and bulimic symptoms among men was entirely attributable to increased alcohol problems among those with higher sensation seeking. While this association may be important on the population level, its clinical significance may be minor.

LEVEL OF EVIDENCE

Level III, well-designed cohort study.

Association between impulsivity and orthorexia nervosa: any moderating role of maladaptive personality traits?

OBJECTIVES

To explore the possible moderating relation between impulsive behavior and maladaptive personality traits in regards to orthorexia nervosa (ON).

METHODS

This cross-sectional study was conducted between July and December 2019 and recruited 519 Lebanese adults from seven community pharmacies randomly selected from a list provided by the Lebanese Order of Pharmacists. The Teruel Orthorexia Scale (TOS) was employed to assess orthorexic eating tendencies, the I-8 measured impulsivity and the Personality Inventory for DSM-5 (PID) evaluated maladaptive personality traits.

RESULTS

Our results showed that, for I-8 subscales, only higher perseverance (B = 0.31) was significantly associated with higher ON. In regard to PID-5 subscales, only higher negative affect (B = - 0.34) was significantly associated with lower ON. Furthermore, significant interactions were found between personality traits and impulsivity to predict TOS-ON.

CONCLUSION

The current results show that female gender, maladaptive personality traits and impulsivity present contributing factors regarding orthorexic eating. Certain impulsivity dimensions were confirmed to interact with personality traits in the prediction of orthorexic eating thereby highlighting possible risk factors and psychopathological mechanisms.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Stressful life events among individuals with a history of eating disorders: a case-control comparison

BACKGROUND

Experiencing stressful life events (SLEs) can negatively impact mental health and increase risk for psychiatric disorders including eating disorders (EDs). Previous research has shown that childhood sexual abuse is associated with some EDs, but less is known about the association between other non-sexual SLEs and EDs.

METHOD

A case-control study of individuals with (n = 495, age mean ± SD = 29.1 ± 9.8 years) and without (n = 395, age = 30.2 ± 11.7) self-reported lifetime history of EDs was conducted to compare history of self-reported SLEs. Participants reported history of sexual (e.g., rape, other sexual assault) and non-sexual (e.g., emotional abuse, assault, bereavement) life events using an adaptation of the Stressful Life Events Screening Questionnaire. Individuals with EDs were divided into ED subtypes along the restricting - binge eating/purging spectrum to examine subtype differences. Logistic regressions were conducted for each SLE and ED subtype to obtain odds ratios (ORs). We report p-values corrected for multiple comparisons.

RESULTS

Exposure to any SLE was significantly more common in individuals with EDs than in controls (OR = 2.47, p < .001). Specifically, rape, other sexual assault, and emotional abuse were significantly more common among individuals with a history of binge-eating/purging ED subtypes (ORs = 2.15-3.58, p's < .01) compared with controls. Furthermore, history of life-threatening disease and loss of a close relative/partner/friend were associated with some ED subtypes. The association between SLEs and EDs was stronger for individuals who had experienced multiple SLEs.

CONCLUSION

By investigating a range of different SLEs, we showed that both sexual and non-sexual SLEs were more common in individuals with a history of EDs (binge-eating/purging subtypes) than controls. Results highlight the importance of assessing a variety of past SLEs in risk assessment for different EDs.

Eating disorders with over-exercise: A cross-sectional analysis of the mediational role of problematic usage of the internet in young people

Eating disorders are widespread illnesses with significant global impact. There is growing concern about how young people overuse online resources leading to mental health sequelae. We gathered data from 639 individuals from a population cohort. Participants were all young adults at the point of contact and were grouped as having probable eating disorder with excessive exercise (n = 37) or controls (n = 602). We measured obsessionality, compulsivity, impulsivity, and problematic internet use. Group differences in these domains were evaluated; and structural equation modelling (SEM) was used to assess structural relationships between variables. Cases had higher scores of obsessional thoughts of threat (Cohen's d = 0.94, p < 0.001), intolerance towards uncertainty (Cohen's d = 0.72; p < 0.001), thoughts of importance and control (Cohen's d = 0.65, p < 0.01), compulsivity (Cohen's d = 0.72; p < 0.001), negative urgency (Cohen's d = 0.75, p < 0.001), and higher problematic usage of the internet (Cohen's d = 0.73; p-corrected <0.001). Our SEM showed significant partial mediation of problematic internet use on both the effect of obsessionality latent factor on cases (z-value = 2.52, p < 0.05), as well as of sensation seeking latent factor on cases (z-value = 2.09, p < 0.05). Youth with eating disorder and heightened exercise levels have increased obsessive thoughts of threat, compulsivity traits and sensation seeking impulsivity. The association between obsessive thoughts and eating disorders, as well as sensation seeking and eating disorders were partially mediated by problematic internet use. Problematic internet use may be playing a role in the development or maintenance of eating disorder symptoms in the background of obsessional thoughts and sensation seeking impulsive traits.

The association of traumatic events and posttraumatic stress disorder with greater eating disorder and comorbid symptom severity in residential eating disorder treatment centers

OBJECTIVE

Traumatic events, posttraumatic stress disorder (PTSD) and related symptoms are commonly associated with eating disorders (ED). Several clinical features indicative of a more severe and complex course have been associated with traumatized ED patients, especially those with PTSD, who may be more likely admitted to residential treatment (RT). Research in this population is sparse but of increasing interest.

METHOD

Adult participants (96.7% female) with EDs entering RT (n = 642) at seven sites in the U.S. completed validated self-report assessments of ED, PTSD, major depression, state-trait anxiety, and quality of life. Presumptive diagnoses of DSM-5 PTSD (PTSD+) were made via the Life Events Checklist-5 and the PTSD Symptom Checklist for DSM-5.

RESULTS

PTSD+ occurred in 49.3% of patients. PTSD+ patients had significantly higher scores on all assessment measures (p ≤ .001), including measures of ED psychopathology, depression, state-trait anxiety, and quality of life. Those with PTSD+ had significantly higher numbers of lifetime traumatic event types, higher rates of almost all lifetime traumatic events, and a greater propensity toward binge-type EDs.

DISCUSSION

Results confirm that ED-PTSD+ patients in RT are more symptomatic and have worse quality of life than ED patients without PTSD+. Integrated treatment approaches that effectively address ED-PTSD+ are greatly needed.

Examining the role of body esteem and sensation seeking in drunkorexia behaviors

PURPOSE

The purpose of the present study was to examine the role of body esteem (BE), sensation seeking (SS), and their interaction in drunkorexia, a behavior pattern marked by calorie restriction/compensation in the context of alcohol consumption. While previous research on drunkorexia has focused on a range of variables, the present study examined two novel variables and their potential interaction: body esteem (weight, appearance) and sensation seeking.

METHODS

A sample of college students (n =488) completed the Body Esteem Scale for Adolescents and Adults, the Brief Sensation Seeking Scale, and the Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale, which measures overall drunkorexia engagement as well as four dimensions: alcohol effects, bulimia, dietary restraint and exercise, and restriction.

RESULTS

Moderated linear regression analyses indicated that SS and BE (weight, appearance) did not interact in predicting drunkorexia. Rather, only main effects were observed; SS, weight esteem (WE), and appearance esteem (AE) were significant in predicting overall drunkorexia engagement. In terms of the drunkorexia dimensions, AE was a significant predictor in the alcohol effects, dietary restraint and exercise, and restriction models. WE was significant in the dietary restraint and exercise model as well as the restriction model. SS was a significant predictor across all drunkorexia dimensions.

CONCLUSIONS

Our findings suggest that both elevated SS and lowered BE are associated with drunkorexia engagement. Implications for practice are discussed. Drunkorexia is a complex and multifaceted behavior pattern; therefore, further research is needed in this area of study.

LEVEL OF EVIDENCE

Level V (descriptive study).

The potential use of N-methyl-3,4-methylenedioxyamphetamine (MDMA) assisted psychotherapy in the treatment of eating disorders comorbid with PTSD

Despite advances in the field, eating disorders (EDs) remain very challenging disorders to treat, especially when comorbid with posttraumatic stress disorder (PTSD). N-methyl-3,4-methylenedioxyamphetamine (MDMA)-assisted psychotherapy for treatment refractory PTSD shows great promise, with two-thirds of participants achieving full remission at 1 year or more at follow-up. PTSD is a common comorbidity associated with EDs, and patients with EDs and PTSD (ED-PTSD) are reported to have higher severities of illness, greater comorbidities, higher treatment dropouts, and poorer outcomes. We hypothesize that MDMA-assisted psychotherapy will be efficacious in the ED-PTSD population for both ED and PTSD symptoms. The rationales for and proposed mechanisms of MDMA-assisted psychotherapy for ED-PTSD are considered from neurobiological, psychological and social perspectives. MDMA is associated with unique psychopharmacological effects, including: 1) reduced fear, 2) enhanced wellbeing, 3) increased sociability/extroversion, 4) reduced self-criticism, 5) increased compassion for self/others, 6) increased interpersonal trust, and 7) alert state of consciousness. These anxiolytic and prosocial effects may counteract avoidance and hyperarousal in the context of psychotherapy for those with ED-PTSD. Other clinical features of EDs that may be amenable to MDMA-assisted psychotherapy include body image distortion, cognitive rigidity, and socio-emotional processing difficulties. To illustrate its potential, personal accounts of individuals with ED-PTSD symptoms reporting benefit from MDMA adjunctive to psychotherapy are described. In addition, the possible risks and challenges in conducting this work are addressed, and future implications of this proposal are discussed.